Impairment Rating Requirements

 

If you elect to file an impairment claim, you will be required to provide Activities of Daily Living (ADL), along with the required medical records dated preferably within the last 12 months

 

The ADLs must be provided by your Specialist Physician, Family Practitioner or Primary Physician in a letter or should be noted in your medical records (for example, History and Physical Examination) in order for the impairment rating to be performed.  For your convenience, please take the attached ADL Questionnaire to your treating physician for his/her completion.  Please remember your medical records and diagnostic examinations must include your current treatments and prescribed medications.  This information should be dated within the last 12 months.  However, if you have no additional medical records to provide, please inform our office in writing, so that we can proceed with your impairment claim.

 

Since you will not be physically examined by a Contract Medical Consultant (CMC), obtaining your current medical records and ADLs from your physician is important in determining your rating.  The lack of medical information, to include ADLs, could potentially affect your impairment rating.  Below is an example of the ADL information needed from your physician, as referenced in the AMA’s Guides, Table 1-2.   

 

Table 1-2  Activities of Daily Living Commonly Measured

                  in Activities of Daily Living (ADL) and

                  Instrumental Activities of Daily Living (IADL) Scales

Activity

Example

Self-care, personal hygiene

Urinating, defecating, brushing teeth, combing hair, bathing, dressing oneself, eating

Communication

Writing, typing, seeing, hearing, speaking

Physical activity

Standing, sitting, reclining, walking, climbing stairs

Sensory function

Hearing, seeing, tactile feeling, tasting, smelling

Nonspecialized hand activities

Grasping, lifting, tactile discrimination

Travel

Riding, driving, flying

Sexual function

Orgasm, ejaculation, lubrication, erection

Sleep

Restful, nocturnal sleep pattern


 

Activities of Daily Living Questionnaire

(Please note: This document must be completed by a physician)

Name:

     

File Number:

     

 

Accepted Conditions

ICD-9 Code

Condition @ MMI[1]

 

Rating Scale

(Each criteria is graded in level of dependence)

 

    1 – Performs independently without reminder or assistance

    2 – Performs with assistance or reminders

    3 – Unable to perform on own, even if assisted

     

 

 Yes   No

     

 

 Yes   No

     

 

 Yes   No

  See attached if more than 3 conditions

Is the claimant terminal?   YES   NO    If YES, estimated timeframe:  _____________________________________________

 

Since the employee will not be physically evaluated for impairment by a Department of Labor physician, the following information regarding the employee’s Activities of Daily Living (ADL) is required.  Rate the activity based only on limitations caused or contributed to by the accepted condition(s).  Address all items using the above rating scale to determine the person’s ability to perform the activity. 

 

Self-Care / Personal Hygiene

Rating

 

Additional comments concerning these activities

 

Dressing/undressing oneself

 

 

 

 

Eating

 

 

 

 

Meal preparation

 

 

 

 

Taking or managing medicine

 

 

 

 

Toileting – getting to and on/off toilet

 

 

 

 

Toileting – keeping self clean and dry

 

 

 

 

Toileting – arranging clothes

 

 

 

 

Bladder/Bowel control

 

 

 

 

Brushing teeth

 

 

 

 

Combing/brushing hair

 

 

 

 

Bathing

 

 

 

 

Light housekeeping

 

 

 

 

Communication 

Rating

 

Additional comments concerning these activities

 

Writing

 

 

 

 

Typing

 

 

 

 

Seeing

 

 

 

 

Hearing

 

 

 

 

Speaking

 

 

 

 

Physical Activity 

Rating

 

Additional comments concerning these activities

 

Standing

 

 

 

 

Sitting

 

 

 

 

Reclining

 

 

 

 

Walking

 

 

 

 

Climbing Stairs

 

 

 

 

 

 

Sensory Function 

Rating

 

Additional comments concerning these activities

 

Hearing

 

 

 

 

Seeing

 

 

 

 

Tactile Feeling

 

 

 

 

Tasting

 

 

 

 

Smelling

 

 

 

 

Other:  Non-specialized hand activities 

Rating

 

Additional comments concerning these activities

 

Grasping

 

 

 

 

Lifting

 

 

 

 

Pulling/Pushing

 

 

 

 

Reaching up, down, out

 

 

 

 

Tactile Discrimination

 

 

 

 

Travel 

Rating

 

Additional comments concerning these activities

 

Riding

 

 

 

 

Driving

 

 

 

 

Flying

 

 

 

 

Arranging travel for self

 

 

 

 

Transferring In and Out of:

Rating

 

Additional comments concerning these activities

 

Bed

 

 

 

 

Tub/Shower

 

 

 

 

Chair/Sofa

 

 

 

 

Vehicles

 

 

 

 

Sexual Function 

Yes

No

 

Additional comments concerning these activities

 

Orgasm

 

 

 

 

 

Ejaculation

 

 

 

 

 

Lubrication

 

 

 

 

 

Erection

 

 

 

 

 

Sleep

Yes

No

 

Additional comments concerning these activities

 

Restful

 

 

 

 

 

Nocturnal Sleep Pattern

 

 

 

 

 

Provide any additional comments to explain what this person can or cannot do in their daily life (if additional space is needed, please provide a typed narrative report and attach it to this questionnaire):

 

 

 

The information listed above is complete and accurate to the best of my knowledge:

 

 

 

 

 

Physician’s Printed Name

 

 

 

 

 

 

 

Physician’s Signature

 

Date

 

 


Activities of Daily Living

Supplementary ADL Specific to:  Breast Cancer

Name:

     

 

File   Number:

     

 

 

Is the patient at MMI for breast cancer and if so what date?  MMI   Yes   No    Date:                          

 

1.    Was removal of part or all of one or both breast required?  If so, describe.

 

 

 

 

2.    Is there resulting lymphoedema in the affected arms?  If so, describe severity.  Is it partially or completely controlled with stockings?

 

 

 

 

3.    Is there a resulting decrease of motion in affected extremities?  If so, detail range of motion for those joints.

 

 

 

 

4.    Is there any decrease in strength in the upper extremities?  If so, describe on a scale of 0-5 with mention of involved motor nerves.

 

 

 

5.    Is there decreased sensation in the affected extremities?  If so, describe with mention of which sensory nerves.

 

 

 

6.    Is there any intermittent or continuous pain of the chest wall?   If so, describe.

 

 

 

   7.   Has there been metastasis?  If so, describe.

 

   Additional Comments:

 

 

 


Activities of Daily Living

Supplementary ADL Specific to:  Skin Cancer

Name:

     

File Number:

     

 

Is the patient at MMI for skin cancer and if so what date?  MMI   Yes   No    Date:                             

 

1.    Is the claimant limited to sun exposure?  If so, describe.

 

 

 

 

2.    Does the claimant have a significant deformity from the skin cancer affecting interpersonal relationships?  If so, please describe.

 

 

 

 

3.    Does the claimant have a deformity or scarring that limits range of motion of any joints?  If so, please state joint and indicate range of motion.

 

 

 

 

4.    Does the claimant require use of a prescriptive drug for the treatment of skin cancer, either intermittently or continuously?  If so, please describe.

 

 

 

 

 

5.    Does the claimant’s skin cancer limit any ADL other than sun exposure?  If so, please describe.

 

 

 

 

6.    Has there been metastasis?  If so, please describe.

 

 

 

 

Additional Comments:

 

 

 

 



[1] Condition has reached maximum medical improvement (MMI) i.e. well-stabilized and unlikely to improve with medical treatment or not required if an illness is in a terminal stage.